From our first days as student pilots, we’re taught to trust Air Traffic Control (ATC). And why not? The voice on the other end of the radio seems to hold great authority, an all-knowing expert who has the big picture right in front of him.
This isn’t just a student pilot problem. Even many experienced pilots get complacent when they’re in ATC’s warm embrace, assuming that terrain, weather and traffic concerns are being handled by someone else. It’s hard to stay paranoid.
But a chilling accident report from 2010 offers an important reminder that controllers can make mistakes, and that only the pilot in command (PIC) can make the final decision about a flight. Reading the blow-by-blow account should make us all a little more paranoid.
The pilot of the Mooney 201 was anxious to get home–that much is obvious. After attending a family event in Jackson Hole, Wyoming, the pilot and his three sons planned to fly back to Minnesota on Sunday, October 24, 2010. Bad weather forced them to cancel, so the pilot booked a commercial flight for the next day. After this plan fell through (due to mechanical issues it appears), the pilot again planned to make the flight in his Mooney, and called twice for a weather briefing on Monday.
While not completely unflyable, the weather certainly wasn’t great, with a 1,000 ft. broken layer and 1 mile of visibility in snow showers. AIRMETs were issued for turbulence, icing and mountain obscuration. The tops weren’t too high, but higher than the Mooney could get to. Overall, it was a late Fall IFR day in the mountains: an easy trip in a King Air perhaps, but a challenge for a normally-aspirated Mooney with no deice.
Adding to the risk was the pilot’s relatively low instrument experience. He had just completed an Instrument Proficiency Check a few days before the Wyoming trip, after more than a year off. He had a total of 3 hours of actual instrument time in the accident airplane.
Nevertheless, the pilot launched out of Jackson Hole on an IFR clearance. Significantly, the clearance was quite different from what he had filed. Instead of a departure to the north, via airways, the controller cleared the Mooney on a south departure, off-airway and at an altitude 5,000 ft. higher than filed. This would turn out to be a critical change.
After climbing to the south, the pilot turned east and soon reported light turbulence and icing at 14,000 ft. At this point, the airplane was on an off-airway route, below the minimum instrument altitude for the area, at gross weight, over the mountains, in the clouds. Due to technical issues, the Mooney was also out of radar contact. Neither the controller nor the pilot recognized how bad the clearance was, but when the airplane appeared again on radar, the controller instructed the pilot to climb to 16,000 ft.
This was the final straw. The airplane, desperately trying to climb, stalled and spun into the ground. It’s possible the airplane encountered a downdraft (the pilot reported “severe mountain wave” just before the crash), but it’s also possible the pilot was disoriented and simply stalled the airplane (he reported to ATC that he might not be able to make it to 16,000 ft. and his groundspeed was getting slow). In any case, it’s clear that the airplane and the pilot were operating on the ragged edge.
As usual, the final cause of the accident was fairly basic: loss of control. But the sequence of events leading up to this final mistake offers a number of lessons for both pilots and controllers. In many ways, this accident fits the classic “Swiss cheese” accident model–no one mistake was instantly fatal, but the combination of being at gross weight, lack of IFR currency, bad weather, time pressure and a bad ATC clearance all conspired against the pilot. There is plenty of blame to go around.
In particular, it’s interesting that the NTSB final report lists both ATC and the radar systems as contributing factors in the accident. While the controller certainly did not cause this accident, it’s fair to say that he didn’t help either. The pilot’s filed route was over lower terrain, with a Minimum En Route Altitude (MEA) of 14,000 ft. and a Minimum Obstruction Clearance Altitude (MOCA) of 13,500. The flight was certainly not a cinch on this route, but it was perhaps possible (the airplane did make it to 14,000 successfully). Taking the pilot off-airway required a minimum altitude 2,500 ft. higher, which turned out to be too much. In addition, the portion of the flight at 14,000 was actually conducted in Class G airspace, since it was below 14,500 ft.–certainly a non-standard procedure.
The JAC tower controller was actually the one who amended the route, not the Salt Lake Center controller. But the center controller never seemed to question the route–he was reacting more than proactively planning.
Technology didn’t help either, as a complicated radar situation meant the Mooney was out of radar contact for almost 10 minutes. When radar contact was reestablished, the Minimum Safe Altitude Warning system immediately triggered, which initiated the clearance to 16,000. In fact, the airplane should have been at 16,000 from the start.
Notwithstanding the ATC errors, it all comes down to the pilot. FAR 91.3 spells it out in black and white:
The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.
The pilot of this flight didn’t seem to take his “final authority” as seriously as he should have. For one, his original flight plan altitude was 9,000 ft., at least 4,000 ft. below the lowest MEA in the area. This was just one of many signs of wishful thinking–there is simply no way out of Jackson Hole at 9,000 ft.
Richard Collins has often argued that safe flying is all about having margins built in. Look at the various margins that were thinned down or completely eliminated on this flight:
- The airplane was taking off from a high altitude airport near maximum gross weight.
- The required cruising altitude was at least 14,000 ft., near the realistic ceiling of the airplane.
- The terrain in the area is some of the highest and most remote in the Western US.
- The weather was fairly low on takeoff, and weather aloft included possible ice and turbulence.
- The wind at the pilot’s destination was forecast to be 27 knots, gusting to 40 upon arrival.
- The pilot was barely instrument current.
- There was self-imposed pressure to get home on this day.
- There wasn’t much planning for oxygen. The Mooney did have a 2-place portable oxygen system on board, and FBO records at JAC show the pilot had the bottle filled. But at 16,000 ft., the lack of oxygen for each passenger was illegal.
All of these factors shaved the safety margins for this flight down to just about zero. If ATC had cleared him on his filed route, it’s possible that, in spite of all these mistakes, the pilot may have made it to his destination. But he didn’t get that route, and that’s exactly the problem with having non-existent margins: if one thing goes wrong, there is no chance to recover.
Besides the decision to fly that day, the pilot’s biggest mistake was to accept a clearance that was simply impossible–between the potential for icing, the lack of oxygen and the required rate of climb, it wasn’t going to happen on this day. This was “get-home-itis” of the worst kind.
Contrary to what some pilots may think, ATC really is on our side and is there to help. Most controllers I deal with are knowledgeable, friendly and professional. But that doesn’t mean we should blindly follow their every direction. They are human and they do make mistakes, as this accident shows.
Weather in particular is something only a pilot can judge. The controller may have good intentions, but his butt isn’t moving at 150 knots, looking at the buildups out the front window. It is well within your rights as a pilot to refuse a vector into bad weather. It’s also within your rights to declare an emergency if you find yourself backed into a dangerous corner. The controller may not be happy, but that can be sorted out after you get on the ground.
Taxiing around an airport is another time to be paranoid. Just because the controller cleared you to cross an active runway does not mean you can blindly wander across the yellow line–remember to look both ways and verify a jet isn’t barreling down the runway towards you (it’s happened to me). The same goes for line up and wait instructions–if you’ve been sitting on the runway for longer than 30 seconds, don’t assume the controller sees you. Be paranoid.
Finally, this accident scenario drives home the reminder to be especially wary if the plan changes at the last minute. If you get a clearance that is significantly different from what you were expecting, slow down and think it through. There could be serious consequences down the road that aren’t immediately apparent. And if that clearance simply won’t work, it’s your right–and your duty–to refuse it. You are the PIC.
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